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10.09.72.00.htm 10.09.72.00. Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Subtitle 09 MEDICAL CARE PROGRAMS Chapter 72 Maryland Medicaid Managed Care Program: Departmental Dispute Resolution Procedures Authority: Health-General Article, §15-103(b)9)i)4, Annotated Code of Maryland
10.09.72.01.htm 10.09.72.01. 01 Department's Complaint Process.. A. The Department shall operate a central complaint program that is designed to:. 1) Be accessible to all enrollees through a toll-free telephone hot-line which:. a) Operates Monday through Friday during extended business hours;. b) Answers enrollees' questions;. c) When appropriate, directs recipients to the MCO staff charged with addressing enrollee complaints;d) When appropriate, attempts to resolve issues by contacting the MCO directly; and.
10.09.72.02.htm 10.09.72.02. 02 Ombudsman Program.. A. The Department shall operate an ombudsman program to:. 1) Investigate disputes between enrollees and MCOs referred by the Department's complaint resolution section;2) Educate enrollees about the services provided by the enrollee's MCO, and their rights and responsibilities in receiving services from the MCO; and3) When appropriate, advocate on the enrollee's behalf before the MCO, including assisting the enrollee to resolve a dispute
10.09.72.03.htm 10.09.72.03. 03 Provider Hotline.. A. The Department shall operate a provider hotline to monitor problems within MCOs that affect enrollee access or quality of care.B. The Department shall, through its provider hotline:. 1) Respond to general inquiries and complaints from MCO providers concerning enrollee access and quality of care;2) Respond to complaints from MCO providers concerning a provider receiving a disproportionate assignment of enrollees from the MCO;3) Attempt to resolve com
10.09.72.04.htm 10.09.72.04. 04 Departmental Complaint Resolution.. A. When a dispute between an enrollee and an MCO involving an action is resolved through the Department's enrollee complaint process, the Department shall:1) Agree with the determination of the MCO to deny, reduce, suspend, or terminate the benefit or service; or2) Disagree with the determination of the MCO to deny, reduce, suspend, or terminate a benefit or service.B. Department Disagreement with MCO's Determination.. 1) If the Department disa
10.09.72.05.htm 10.09.72.05. 05 Enrollee Appeal.. A. From the decisions set forth in §B(1) and (2) of this regulation, a waiver-eligible individual may exercise appeal rights pursuant to State Government Article, §10-201 et seq. Annotated Code of Maryland, without first exhausting the MCO's appeal process.B. A waiver-eligible individual may appeal a Department decision:. 1) Agreeing with an MCO's determination to deny, reduce, suspend, or terminate a benefit or service; and
10.09.72.06.htm 10.09.72.06. 06 MCO Appeal.. A. From the decisions set forth in §B(1)8) of this regulation, an MCO may exercise the appeal rights set forth in this regulation.B. The following Department decisions are appealable by the MCO or MCO applicant:. 1) Denial of the MCO applicant's application to become an MCO;. 2) Decision to terminate the MCO's provider agreement;. 3) Decision to impose a fine or other sanction on the MCO;.
10.09.72.9999.htm 10.09.72.9999. Administrative History Effective date:. Regulations .01―06 adopted as an emergency provision effective November 8, 1996 (23:25 Md. R. 1730). Regulations .01―06 adopted effective March 10, 1997 (24:5 Md. R. 408). Regulations .01, .02, and .03 amended as an emergency provision effective July 1, 1998 (25:16 Md. R. 1261) amended permanently effective January 1, 1999 (25:26 Md. R. 1925)Regulation .01 amended effective June 30, 2008 (35:13 Md. R. 1180).
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